Following America In The Pandemic
In health, America has been the standard that most countries in the developing world aspire towards — the coronavirus might have changed that
Being a practicing physician in an underdeveloped country, I — and virtually everyone else I work with — consider the US health practices as the gold-standard. The resources are unlimited, access to advanced diagnostics and treatments is universal, every step is based on evidence and follows proper guidelines, outside the hospital door may be politics but inside patients’ rights and science reign supreme, and the list of virtues goes on. With little to no research of our own and deeply corrupt and politically influenced health systems, the US clinical guidelines are the ones we aspire to follow and their patient-centric, science-based system is what we dream of.
Time and again, revelations about the big pharma, insurance scandals, and research frauds cast a shadow of suspicion on the holy grail of the American health system and medical academia but, given the perceived credibility of the system as a whole and the utter lack of the same in our world, they fail to make a permanent dent — until this pandemic at least. Whether this will change with the US apparent failure to tackle the coronavirus crisis is too soon to tell. However, there is no denying that the coronavirus has exposed the US health system in more than one way. The chinks already present in its armor are now visible from a distance.
Because he is (was) the President
On October 2, Donald Trump revealed in a tweet that he has tested positive for SARS-CoV-2. The news, expectedly, spread faster than the Californian wildfires. Over the days to come, what caught my attention was the number of proven and unproven treatments he received for his reportedly mild to moderate illness. Here is the list shared by his personal physician, as reported here and here:
· A monoclonal antibody cocktail from Regeneron
· Vitamin D
It is unclear whether the President was using the last four items prior to his diagnosis or started taking them later on. Interestingly, there is no mention of hydroxychloroquine. It seems the President has finally given up on his ‘game-changer’ drug.
A newly diagnosed coronavirus patient with a non-severe disease is unlikely to receive all or even some of the medicines mentioned, in or outside the US. Not because of availability or cost, but because the current clinical guidelines don’t recommend their use the way they have been used in the President’s case. The antibody cocktail from Regeneron, for instance, is currently being tested in an ongoing clinical trial where preliminary results have hinted towards some efficacy, equally at doses of 2.4 and 8 grams. Donald Trump was prescribed the 8 g dose, presumably ‘out of an abundance of caution’, reports Jon Cohen of ScienceMag, quoting George Yancopoulos, chief scientific officer at Regeneron. Notably, this novel therapy is yet to complete phase 3 trials and is not recommended to be used outside of a clinical trial.
Similarly, in the pivotal UK’s Recovery trial, dexamethasone was shown to be effective at reducing mortality in severely ill patients, but not in mild to moderate cases. Indeed, experts have warned that injudicious use of the drug can do more harm than good given its potential to suppress immunity. Donald Trump nonetheless received dexamethasone, despite no apparent indication. Being president can trump evidence it would seem — no pun intended.
The VIP syndrome — It occurs in the US too
As Perry Wilson, MD, at Yale has pointed out, Donald Trump’s case might be a classic example of ‘the VIP syndrome’. Physicians and hospitals often go out of their way in managing patients of elite status and importance, given the stacks involved. The extra efforts, however, can often prove detrimental to the VIP’s health. Apart from the health concerns, the socio-political implications of this phenomenon are equally important, if not more.
Political and social pressures in hospitals are a constant menace in our part of the world. There is an established VIP culture, thanks to which science, medical ethics, and rules often find themselves in the backseat. When faced with such a situation we constantly remind ourselves that this will never happen in the US. There, science is paramount and politics stay outside the hospital. It is heartening to know that even in the US, science is the king of the hospital until it is not.
Admittedly, the VIP syndrome is a more benign situation than the social evil of the VIP culture and often springs from good intentions and nice sentiments. While VIP culture flies in the face of medical ethics, justice, and equity, these values are — or at least they appear to be — not violated by treating VIPs with the extra bit of caution and rigor. At a more fundamental level though both situations share common roots. They stem from the same social fallacy of, consciously or subconsciously, imparting more value to one life than another — either on part of the attending physician, society, or the person in question himself.
The US can fail too — And it does so spectacularly
The extraordinary treatment of POTUS will more likely be considered a difference of opinion in the medical world rather than bending of rules but still, it gives an impression of personal whims and speculations taking precedence over science and evidence — a recurring theme in the United States’ response to the pandemic.
When the current crises started gathering momentum, in late February, we in the third-world feared the worst. Ill-educated masses, general lack of awareness about hygiene, social and religious perceptions, and above all fragile health systems already operating at the limits of their capacity — any projection of worst-case scenarios seemed like an understatement. When highly regarded health-systems like Italy were pushed to the brink, the fears were compounded.
With the pandemic far from over and a possible second wave lurking around the corner, it is too early to speculate but so far, for many of us, the worst of predictions — thankfully — haven’t materialized. As fortunate as it is, it’s still a scientific conundrum. Although the response of the global scientific community in terms of research is laudable, the fact remains that nearly a year on from the emergence of the virus on the scene, we are still left with more questions than answers. One crucial mystery has been this seemingly low spread and mortality in various underdeveloped countries of Africa and Asia.
In contrast, the US has been affected badly. The primary problem, however, is probably not the country’s inability to control the pandemic — predicting the course of emerging infectious threats is difficult and pre-emptive measures can be anybody’s guess. Rather, the complete lack of foresight, mismanagement to a level that an economy as strong as the US was unable to provide proper protective equipment to its health officials despite having ample time to prepare, testing strategies completely inadequate for the graveness of the situation, and above all the unscientific response of the men-in-command and the egregious politicization of the whole process is what has cast doubt on the United States’ ability to lead and carry forward the rest of the world in times of crises.
What is making the matter worse is the apparent lack of realization that things are messed up and somewhere along the course of events wrong turns were taken. It seems that given the chance, the authorities in charge will do it all over again. Self-accountability, a reliable system of scrutiny, identifying and admitting shortcomings, and learning from mistakes are the essential ingredients of any trustworthy system. Forgo them and people will think twice before following you.
Health professionals and institutions in resource-poor countries look towards America for guidance and inspiration. This becomes urgent in times like the current pandemic. Though not usually recognized, this mentorship often goes beyond the provision of scientific research and clinical guidelines — the socio-political connotations of tackling a health crisis can have an equally important impact. Apart from a few hiccups like the mixed messages on disease transmission, which are probably acceptable given the novelty of the situation, clinical guides and research have generally been up to the mark. On the other hand, the quasi-health opinions — from outright denial that a real threat actually exists and promotion of prescription medications on personal whims to conspiracy theories circulating in the elite circles — have been anything but representative of a global health leader.
A vacuum of leadership
The editors of the prestigious medical journal, New England Journal of Medicine, have laid bare the leadership vacuum in the US which has ‘turned a crisis into a tragedy’. Thankfully, despite their reliance on the US for strategies and knowledge, the third world has apparently done better. While the reasons for the underdeveloped nations’ relative success are not entirely clear, countries like China, South Korea, Singapore, and New Zealand succeeded by adopting clear, science-backed plans.
There may be a vacuum of leadership inside the US, but followable examples are plenty around the world. It might be high time the US took a leaf out of someone else’s book.